1. Introduction

The purpose of history taking and physical
examination as stated earlier is to collect information from the patient,
examine the patient, and to understand the patient’s
problems.

The traditional history taking has several parts, each
with a specific purpose. In order to achieve maximum success, the medical
history must be accurate, concise, and systematic. Following is a STANDARD
outline of the different components of history taking in sequential order.

The introductory materials in the health history consist
of collecting the following information from the patient:

1.1. Data Collection

The following information is obtained in all patients
to gain a basic understanding of the patient:

Date of
visit:

Record number:

Name (last):

(first):

(middle):

Home address:

Business address:

Occupation:

Date of birth:

Sex:

Marital status
(S/M/D/W):

Height:

Weight:

Referred by:

1.2. Chief Complaints

Described in the patient's own words the reason for
seeking care:

e.g.; "I have a toothache" or "I
need routine cleaning" or "I need a root canal"

1.3. Present History

List in clear chronological order, the details of the
problem or problems for which the patient is seeking care. You will determine
by interrogation the time line of:

When did the patient’s problem(s) begin?

Where did the problem begin?

What kinds of symptoms did the patient experience?

Has the patient taken any treatment for the problem?

Has the treatment had any effect on the patient or has the
treatment not improved or altered the patient’s condition?

It is also important to determine if the problem(s) have
affected the patient’s lifestyle. that is, have the symptoms experienced
because of the problem(s) caused any incapacities?

1.4. Past History

Gives you an insight about the health status of the
patient up until now. Check with the patient for the presence or absence of the
following conditions by eliciting the symptoms and signs associated
with those conditions:

Also determine if the patient is currently on steroids or has the patient been prescribed any
corticosteroid preparations within the past two
years. Check if the patient has any known allergies
to any drugs like NSAIDs, aspirin, codeine, morphine, penicillin, sulpha, or
any local anesthetics.

Endocrine disorders:

Common disorders to be ruled out (in
the medical lingo, it means to establish that a disease is not present) in the
patient are: diabetes, hyperthyroidism, hypothyroidism, adrenal
disorders—Addison’s disease or Cushing’s
syndrome.

Fits or faints:

Rule out different kinds of seizures in the
patient—grand mal epilepsy, petit mal epilepsy, temporal lobe or
psychomotor epilepsy, or localized motor seizures.

Determine the cause or causes for admission. Did the
patient have any history of accidents or injuries? Was the patient given any
anesthesia—local/general? Were there any complications during the
hospital admission due to the anesthesia or the medical/surgical condition?
Was the patient given any blood transfusion during hospitalization?

Has the patient developed jaundice due to viral
hepatitis or alcoholic hepatitis, gall stones, etc.? Is there any history of
gall bladder dysfunction? Is there any indication of improper liver
function?

Kidney disorders:

Is there any indication of kidney dysfunction or renal
stones, urinary tract infections, or renal failure or renal
transplant?

1.7. Review of Systems (ROS)

In this portion of the history, all organ systems not
already discussed during the interview are systematically reviewed. ROS is a
final methodical inquiry, prior to physical examination. It provides a thorough
search for further, as yet unestablished, disease processes in the patient. If
the patient has failed to mention symptoms, this process of ROS would remind
the patient at this point. Also, if you have unknowingly omitted certain points
of inquiry, now would be the time to establish those.

Following are the topics to be reviewed for
each organ system:

1.7.1. Constitutional

Any history of recent weight change

Any history of anorexia (loss of appetite), weakness,
fatigue, fever, chills, insomnia, irritability or night sweats

1.7.2. Skin

Any history of skin rashes—acute or chronic, is it
unilateral or bilateral

Any history of allergic skin rashes

Any itching of the skin

Any history of unhealed lesions (probably due to:
diabetes; poor diet; steroids and other causes of decreased immunity,
especially AIDS)

1.7.3. Head

History of seizures. Are they general (with or without
loss of consciousness) or focal? Are there any motor movements?

Is there any history of head injury?

1.7.4. Eyes

Check for vision, history of glaucoma ( could cause pain
in the eyes), redness, irritation, halos (seeing a white ring around a light
source), blurred vision

Any irritation of the eyes, excessive tearing, which
can be associated with frequent allergic symptoms?

1.7.5. Ears

Any recent change in hearing

Any pain in the ears or ringing in the ears (tinnitus)?
discharge?

Any history of vertigo (dizziness)?

1.7.6. Lymph Glands

Any history of lymph glandular enlargement in the neck
or elsewhere? Are they tender/painless? How were they first
noticed?

Are they freely mobile or are they adherent to
the underlying tissues?

1.7.7. Respiratory System

History of frequent sinus infections

Postnasal drip

Nosebleeds

Cough (with/without expectoration)

Color of sputum, when present

History of sore throat

History of shortness of breath on exertion or at
rest

Any history of wheezing (may be due to asthma,
allergies, etc.)

Hemoptysis (blood in the sputum): may be due to dental
causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral
stenosis or CHF (congestive heart failure). Determine if it is a blood-tinged
sputum or there is frank blood in the sputum.

Any history of bronchitis, asthma, pneumonia, emphysema,
etc.

1.7.8. Cardiovascular System

History of chest pain or discomfort

History of palpitations: were the palpitations
associated with syncope (loss of consciousness)?

History of either hypertension or hypotension

Does the patient experience any paroxysmal nocturnal
dyspnea (shortness of breath during sleep, in the middle of the night)? Is
there any SOB in relation to exercise or exertion?

Any history of orthopnea (shortness of breath when lying
flat in bed)? Does the patient use more than one pillow to sleep? Has this
always been the case, or has the patient recently started using more pillows?

History of edema (site of edema—legs, face, etc.)

Any history of leg pains, cramps? Are they relieved by
rest (this is suggestive of intermittent claudication) or is it unremitting?
(this is muscular)

Any history of murmur(s), rheumatic fever, varicose
veins?

Any history of hypercholesterolemia, gout, excessive
smoking, i.e., conditions which can lead to or worsen heart disease

1.7.9. Gastrointestinal System

History of bleeding gums, oral ulcers or
sores

History of dysphagia (can the patient point out and
describe where the difficulty swallowing exists?)

History of heartburn, indigestion, bloating, belching,
flatulence

History of nausea: is it related to food? Is it one of
the many symptoms due to GI (gastrointestinal) disease?

Vomiting: is there any associated weight loss,
psychosocial factors, or are medications causing it?

Jaundice: is there a viral cause, gallstones, associated
family history?

History of diarrhea/constipation

Any change in color of stools

1.7.10. Genitourinary

History of polyuria (excessive urination) due to
diabetes, renal disease, unknown cause, etc. Check if this has been a recent
change

History of nocturia (getting up at night to go to the
bathroom). Is this a recent change?

History of dysuria (painful urination). If it is
because of urinary tract infection (UTI), the patient will experience frequency
and urgency in addition to dysuria. STD will also be associated with similar
symptoms (was treatment for STD completed?)

History of renal stones, pain in the loins, frequent
UTIs

1.7.11. Menstrual History

Date of LMP (last menstrual period). Always precede this
question by informing the patient that she has to get x-rays done, so you need
to know if she is pregnant; thus, the need to know her LMP

Any history of menorrhagia (heavy periods)

History of use of birth control pills

1.7.12. Musculoskeletal System

History of joint pains—determine location: is it
acute or chronic? Unilateral or bilateral? More in the morning or evening? Are
there associated systemic symptoms?

Any history of rheumatoid arthritis, osteoarthritis,
gout, etc.

1.7.13. Endocrine System

History of symptoms due to diabetes, i.e., polyuria,
polydypsia, polyphagia1, weight change